At first glance, the GOP presidential candidates seem virtually identical in their health policy platforms. They are unanimously opposed to last year’s health law, favor reducing federal investment in Medicare and expanding state flexibility in managing Medicaid.
But there are important distinctions in policy and tone, such as Mitt Romney’s record as the governor who signed Massachusetts’ landmark health reform and Rep. Ron Paul opposes limiting malpractice awards, instead advocating tax credits for “negative outcomes” insurance so patients can be compensated for medical mistakes. Rick Santorum, who has criticized what he says is Democrats’ “love” of entitlement programs, voted for the Medicare Part D prescription drug program when he was a U.S. senator.
KHN has assembled this chart to show in detail where eight current and former candidates stand on major health care issues. To compare and contrast their positions, you can scroll down the page or jump to from these links:
Active Candidatesradical” for Americans. His May 15 appearance on NBC’s Meet the Press drew a lot of media attention. In December commended Ryan for backing off his earlier plan and teaming with Sen. Ron Wyden, D-Ore., on an altered premium support proposal that would allow seniors to stay in traditional fee-for-service Medicare. Supports making structural changes to Medicare that would give beneficiaries more options and less government control while seeing to it that seniors have more ‘skin-in-the-game.’ Wants to “create more choices in Medicare,” allowing consumers to choose either the current structure of the program or a private option thereby creating “price competition to lower costs.” Health savings accounts would be among the options. Currently, Medicare beneficiaries are not allowed to sign up for HSAs. Supports restructuring Medicare’s reimbursement systems to reflect quality of care and give entitlement programs like Medicare “latitude to design benefits to encourage, incentivize, and reward healthy behaviors.” Describes himself as a strong advocate of strengthening Medicare, mentioning his efforts to push for the 2003 Medicare Modernization Act that created the Medicare Part D prescription drug program. Ron Paul Argues that Medicare and other entitlement programs create undesirable dependence on the government, worsening the nation’s financial woes. Views the Medicare’s Part D prescription drug program as an unwarranted expansion of the government’s role in health care and a “reminder that the GOP sometimes can’t resist the temptation of big government.” Didn’t take part in Medicare when he practiced medicine; offered low-cost or free care to those who couldn’t afford his services. Proposes redirecting resources from defense spending and foreign aid to fund Medicare for those already enrolled, while weaning younger people away from such assistance programs in favor of free market approaches. “Why exactly should Americans be required, by force of taxation, to fund retirement or medical care for senior citizens, especially senior citizens who are comfortable financially? And if taxpayers provide retirement and health care benefits to some older Americans who are less well off, can’t we just call it welfare instead of maintaining the charade about ‘insurance’ and ‘trust funds’?” — Texas Straight Talk weekly address, Nov. 2010 Mitt Romney Has supported various renditions of the premium support model for Medicare that would give seniors a set amount to purchase insurance coverage. Most recently embraced proposals that would allow seniors to use that money to remain in fee-for-service Medicare. Unveiled his own premium support plan last November that would retain the option of fee-for-service Medicare. All plans would have to offer coverage at least comparable to what Medicare provides today. He offered few details, however, and critics say that capping the government’s contribution would likely mean that beneficiaries pay more for the same benefits. He embraced a similar proposal by Rep. Paul Ryan, R-Wis. and Sen. Ron Wyden, D-Ore., in December. Last spring, Romney supported a premium support plan that Ryan wrote and the House approved in its budget resolution, which would have ended fee-for-service Medicare. At the time, Romney said he would have signed it as president, but that he preferred to create his own proposal. Supports the notion that wealthier seniors should pay more towards their health coverage. Wants to publish federal yearly balance sheet to help people understand the impact of entitlement spending on the budget and economy. Promises he won’t slice benefits for current seniors or jeopardize their retirement security. Rick Santorum Supports the Medicare changes advanced by House Budget Committee Chairman Paul Ryan, R-Wis., including replacing the current program with a voucher system. Considers his 2003 vote for the Medicare prescription drug program to be a “mistake” because it is “universal” in nature when only about 15 percent of seniors had trouble with drug coverage, though he likes the private-market structure of the program.. Marketplace Newt Gingrich Supports tort reform to decrease unnecessary and costly law suits. Promotes a 21st-century personalized intelligent health system that would empower patients to access accurate and timely knowledge about their health and treatment options through the use of information technology. Believes market competition allows consumers to make better health choices at lower prices and that patients and consumers should have access to information to make more informed choices. Believes in several insurance reforms including giving people the choice of a generous tax credit or the ability to deduct a certain amount of the value of their health insurance, allowing the purchase of insurance across state lines and strengthening laws that prohibit insurers from cancelling or increasing rate increases to those who become sick while insured. Supports expanding Health Savings Accounts (HSAs) throughout the health care system. Was an early, strong proponent of tax-preferred medical savings accounts, which preceded health savings accounts. Successfully advocated for Congress to create the first demonstration project for MSAs in 1996. Advocates rewarding health and wellness by giving health plans, employers, Medicare, and Medicaid more flexibility to encourage healthy behaviors. Proposes encouraging medical breakthroughs to patients by reforming the Food and Drug Administration. Wants to invest in research for health solutions that are urgent national priorities, such as brain conditions that are costly for the system including Alzheimer’s, autism and mental health. “The lesson of nearly four hundred years of entrepreneurial, technology and science-based free market capitalism is very clear. You should expect to get more choices of higher quality at falling prices. This is the opposite of the rationing mentality of some left-wing politicians and the scarcity mentality of too many bureaucrats. We need to bring these concepts into health and health care. We must insist that doctors, hospitals, medical technologies, and drugs have both quality and cost information available on-line so people can make informed decisions.” — “Winning The Future“ Ron Paul Introduced legislation in 2009 to allow patients and physicians to opt out of the electronic medical records system set up by the federal government, to refuse to have those records shared with a third party and to repeal a federal program establishing a “unique health identifier” for each patient. Supports creating tax credits and deductions for all medical expenses, exempting terminally ill people from paying the employee portion of payroll taxes, providing a payroll deduction to workers who are caring for a spouse, parent or child with a terminal illness. Opposes caps on awards in medical liability cases. Endorses a new tax credit for “negative outcomes” insurance bought by patients before medical treatment so they can be compensated for medical mistakes. Says it would reduce “the burden of costly malpractice litigation.” Supports allowing insurers to sell across state lines, as well as association health plans. Wants to expand high-deductible health savings accounts. Mitt Romney Wants to “strengthen” high-deductible health savings accounts by allowing consumers to use them to pay insurance premiums. Seeks to cap non-economic damage awards in medical malpractices law suits and favors giving states grants to fund other ways to deal with the liability issue, such as health care courts. Urges restricting federal regulation of health care insurance, although he supports limited rules to bar insurers from denying coverage to those with preexisting conditions when they have had coverage for a specified period of time. Says insurers should be allowed to sell their products across state lines. Supports creating a tax deduction for people who obtain health insurance on their own. Favors allowing individuals and small businesses to join together to buy insurance. Supports individual control over their health coverage – meaning peole should own their insurance and be able to continue to keep it during the course of their lives. Romney’s explanation of this position during a campaign stop in New Hampshire drew criticism because, in the context of insurance companies, he said he likes “being able to fire people.” “I want people to be able to own their own insurance, if they wish to. And to buy it for themselves and perhaps keep it the rest of their lives and to choose among different policies offered from companies across the nation,” he said. “That means the insurance company will have an incentive to keep you healthy. It also means, if you don’t like what they do, you can fire them.” – Nashua, New Hampshire, Jan. 9 Rick Santorum Supports capping medical liability awards to $250,000. Voted against allowing re-importation of prescription drugs from Canada. Opposed allowing patients to sue HMOs and collect punitive damages. Health Reform Philosophy Newt Gingrich Advocates for tax credits or deductions for purchasing insurance. For those who choose to remain uninsured, he has explored diverting the subsidy they could have gotten to safety net medical providers, who would deliver any needed care. Founded the Center for Health Transformation, a corporate for-profit organization focused on the health care industry. The Center, which has been the topic of coverage by news outlets including The Washington Post and The New York Times, advances a range of market-based reform concepts and has been a vocal opponent of the 2010 health law. Has worked on healthcare issues since 1974 and wrote a book called “Saving Lives & Saving Money” in 2002, which outlines proposals to “transform” the health care system by improving quality and reducing errors through increased transparency, better use of technology such as electronic medical records, and giving consumers greater ability to make decisions. Says in his “21st Century Contract with America” that repealing the 2010 health law will be the first task of his administration. Supports replacing the health law with proposals that include medical liability reform, insurance portability, improved price competition, and that emphasize electronic records and health savings accounts. Opposes the 2010 health law’s individual mandate, but has been criticized for his previous support of it. Gingrich advocated the concept, in collaboration with the Heritage Foundation, when he opposed Hillary Clinton’s health care reform efforts in the 1990s. Many credit the conservative think tank as the original source of the mandate idea. Calls for states to set up high risk pools to cover uninsured people who have become too sick to buy health insurance. “As I carry the banner in fighting for the repeal of Obamacare, I will advocate for specific replacement health policies that will create a free market framework for healthcare, provide affordable, portable, and reliable healthcare coverage, and establish a healthcare safety net focused on those in need. This system will assure healthcare for all with no individual mandate or employer mandate of any kind.” — 21st Century Contract with America Ron Paul Outspoken opponent of the health law on policy, procedural and constitutional grounds. Believes the individual mandate is unconstitutional; introduced legislation to end the mandate Cites his experience as a physician to oppose the implementation of managed care: “We don’t have a right to medical care.” Introduced legislation to create a market-based system “that reflects consumer choices while rationally pricing services.” “If medical care is provided by government, this can only be achieved by an authoritarian government unconcerned about the rights of the individual.” — Statement, Sept. 23, 2009 Mitt Romney Known for working with Massachusetts Democrats to enact the precedent-setting 2006 state law requiring most residents to have insurance. Supported – as part of this law – the creation of an online marketplace called the Health Connector, through which individuals and businesses can purchase insurance. Argues that the federal law didn’t grow out of the Massachusetts law, saying the state reforms were tailored specifically to meet the needs of the state. Says, if elected, he’d allow states to opt out of the federal health law and encourage Congress to repeal it. “Mr. President, if, in fact, you did look at what we did in Massachusetts, why didn’t you give me a call and ask what worked and what didn’t? … I would have told you, Mr. President, that what you’re doing will not work. It’s a huge power grab by the federal government. It’s going to be massively expensive, raising taxes, cutting Medicare.” — GOP candidate debate, June 13, 2011 Rick Santorum Places high priority on repeal of the health law. During a speech at the 67th anniversary of D-Day, Santorum criticized the health care law and said that American soldiers stormed the beaches of Normandy and “risked everything to make sure you could make your own decisions on your healthcare plan.” Strongly opposes more federal funding for health coverage and involvement in health programs. Has said that Democrats love entitlement programs and are trying to get more people “hooked” on health care benefits. Medicaid Newt Gingrich Supports giving states more freedom and flexibility to customize their Medicaid programs into block grants, a policy he pushed for unsuccessfully while speaker of the House in the mid-1990s. Believes Medicaid reforms must recognize three distinct populations: people with disabilities, the poor and the elderly poor. Supports adjusting Medicaid reimbursement models to reward quality of care and create incentives for beneficiaries to seek out facilities that deliver the best care at the lowest cost. Says Medicaid beneficiaries should be free to choose a health savings account as part of their coverage. Voted for the creation of the Children’s Health Insurance Program as part of the Balanced Budget Act 1997 and supported an extension of the program 2007. Did not support the 2009 stimulus package, which included increased federal funding to states for Medicaid. Ron Paul Voted against expanding CHIP in 2009 and 2007. Opposed stimulus package, which included a temporary enhanced federal Medicaid contribution and short-term extension of COBRA coverage. Mitt Romney Opposes the health law’s expansion of Medicaid coverage to more than 30 million people. Backs block grants for Medicaid to allow states to use capped federal contributions to run Medicaid as they see fit. “My view is get the federal government out of Medicaid, get it out of health care. Return it to the states.” – South Carolina GOP Primary Debate, Jan. 20. Rick Santorum Supports dramatically overhauling Medicaid in order to reduce national spending. Cites the 1996 welfare reform law, which substantially reconstructed the nation’s welfare system and turned much of its administration over to the states, as a model for how Medicaid should be revamped. Santorum was a member of the Senate when that legislation was drafted.
Inactive Candidatesqualified her support, saying she thought it could hurt senior citizens. Supports reducing future Medicare benefits for people who are now 55 or younger. Claimed during the health overhaul debate that the law would create death panels and lead to rationing. Opposes creation of the 15-member Independent Payment Advisory Board, saying the panel, charged with making binding recommendations to reduce Medicare spending, will cause seniors to lose control over their care. Voted against allowing the government to bargain with pharmaceutical companies to get lower drug prices for Medicare Part D, arguing it would lead to draconian price controls. Voted to override President Bush’s veto of the Medicare Improvements for Patients and Providers Act of 2008, which temporarily blocked a Medicare pay cut for physicians, prohibited some Medicare Advantage marketing practices, expanded coverage of mental health services and authorized Medicare to cover new preventive services. “Senior citizens will lose control over what they actually get in Medicare, because a politically appointed 15-member board that’s unelected and unresponsive to the will of the people called IPAB will make the decisions about what care we get and what care we don’t.” — Bachmann to conservative bloggers, June 2011 Herman Cain (campaign suspended on Dec. 3) Supports the Ryan plan to revamp Medicare. Embraces the concept of a voucher system for Medicare and has said that the program needs a total restructuring as outlined in that proposal. Cain’s 9-9-9 tax plan would eliminate the payroll tax which currently funds Medicare and Social Security. “We don’t need to come up with another plan. The people who are backing away from Ryan’s plan, which is very well thought out … they simply lack courage. Don’t back away from something simply because it’s controversial or because it’s difficult to explain to the American people.” — Fox News interview, May 2011 Jon Huntsman (campaign suspended on Jan. 16) Backed the Ryan budget plan, which proposed turning Medicare into a “premium support” program to curb spending. Supported the August 2011 debt-ceiling deal, which leaves entitlement programs untouched in its first phase; the only GOP presidential hopeful to take this position. “I admire Congressman Paul Ryan’s honest attempt to save Medicare. Those who disagree with his approach incur a moral responsibility to propose reforms that would ensure Medicare’s ability to meet its responsibilities to retirees without imposing an unaffordable tax burden on future generations of Americans.” — Wall Street Journal, May 31, 2011 Rick Perry (campaign suspended on Jan. 19) Argues that, based on the 10th Amendment, states should be able to opt out of Medicare and develop their own means of providing health care. Led the charge in 2005 against a provision of the Medicare Part D program, which was designed to relieve states of prescription drug costs for low-income elderly people. The policy required states to pay a portion – known as “clawback payments” – of their savings back to the federal government. Perry argued this was unfair to states that had already reduced their Medicaid drug spending. His administration filed a lawsuit in 2006 charging that the policy was unconstitutional. “I think every program needs to stand the sunshine of righteous scrutiny. Whether it’s Social Security, whether it’s Medicaid, whether it’s Medicare. You’ve got $115 trillion worth of unfunded liability in those three. They’re bankrupt. They’re a Ponzi scheme.” — Newsweek interview, Aug. 12, 2011 Marketplace Michele Bachmann (campaign suspended on Jan. 4) Cites her experience as co-owner with her husband of Bachmann and Associates, a Christian-based mental health care counseling center that employs nearly 50 people. Sponsored a bill in 2009 that she says would make medical expenses, including insurance premiums, tax deductible for everyone. Supports the expansion of high-deductible health savings accounts. Seeks to allow small businesses to band together through trade associations to purchase health insurance for their employees at a lower cost than they can get individually. Backs tort reform to curb medical malpractice awards. Herman Cain (campaign suspended on Dec. 3) Emphasizes his understanding of small business health care concerns, often citing his experience as head of the National Restaurant Association, on the Board of Directors and as chairman of the Federal Reserve Bank of Kansas City, the CEO and president of Godfather’s Pizza Inc. and member of the National Commission on Economic Growth and Tax Reform. Supports health plans sponsored by associations. Proposes “leveling the playing field under the current tax code” and allowing health insurance premiums to be deducted whether they are purchased by an employer or employee. Supports loser-pay laws in which plaintiffs who lose frivolous lawsuits pay the legal expenses of those they sued. Calls for loosening restrictions on Health Savings Accounts, to enable consumers to carry over leftover funds into the next calendar year. “When I ran the National Restaurant Association, which today has 14 million employees, we wanted to design a system for health insurance that was going to be customized for our industry. We could not do that. We need to be allowed to do that, and so should other organizations and other associations.” — GOP debate, Sept. 2011 Jon Huntsman (campaign suspended on Jan. 16) Pushed as governor for the completion of Utah’s all-payer claims database. Campaigned for reelection in Utah promising to overhaul the state’s health system and trim the number of uninsured residents. Signed Utah laws that established a task force to consider comprehensive health system changes, created a tax credit for individuals purchasing a health insurance policy on their own and began setting up an electronic medical records system. “It is unacceptable that a young father in Clarkston, Utah who works for a small business and wants to buy insurance for his family is denied coverage because of minor ailments. Should eczema or post-partum depression preclude a family from getting affordable health insurance?” State of the State speech, 2008 Rick Perry (campaign suspended on Jan. 19) Believes policymakers can best improve access to health care by working to improve the economy and increase jobs so that more people are covered under employer-sponsored health plans. Opposes any federal action that would undermine states’ ability to regulate the health insurance and protect consumers. Supports medical liability reform/tort reform to reduce frivolous lawsuits and reduce health care costs; cites a Texas measure that became law in 2003 as evidence of effectiveness. Promoted investments in adult stem cell infusion and helped pass a health care measure that authorized creation of a state adult stem cell bank. He also personally received lab-grown stem cells during a spinal fusion to help with a back injury. Supports allowing insurance companies to sell across state lines and efforts to help small businesses get better rates on health care plans. Health Reform Philosophy Michele Bachmann (campaign suspended on Jan. 4) Founded the House tea party caucus and is a vociferous critic of the health law. Co-sponsored legislation in the House to defund the health law. Introduced in Jan. 2009 the “Health Care Freedom of Choice Act” to allow individuals to deduct all medical expenses. “The American people spoke soundly and clearly at the ballot box in November and they said to us, ‘Mr. Speaker, in no uncertain terms, repeal this bill.’” — Remarks to the House of Representatives, Jan. 19, 2011 Herman Cain (campaign suspended on Dec. 3) Supports repealing the 2010 health law “in its entirety.” Believes in less government regulation and taxation of the health care marketplace, and favors “patient-centered, free market reforms.” Refers to the 2010 “health reform” law as “health deform” on his campaign website. Opposes the individual mandate. Says he would have died of cancer if the health law had been in place in 2006. Politifact later rated this statement to be “false.” Opposed the 1994 health reform effort led by Hillary Clinton Challenged President Bill Clinton on Hillary Clinton’s 1994 health reform efforts, questioning its effects on business during a nationally televised town hall meeting in 1994. Jon Huntsman (campaign suspended on Jan. 16) Supports repealing the health law, which he says is “top-heavy” and “government-centric.” Signed in 2008, while governor of Utah, a law to overhaul health care and set up an insurance exchange –- one of only two in the United States. Opposes a federal mandate to require individuals to have health insurance. Rick Perry (campaign suspended on Jan. 19) Called the health law unconstitutional and a “train wreck of a plan” and supports its repeal. Opposes the creation of a state-based health insurance exchange, as called for in the health law; his veto threat derailed a GOP effort to create a state exchange. Did not commit to the health law’s high-risk insurance pool program, which was created by the health law, citing lack of program rules and reliable federal funding. Believes states should develop state-specific health care reforms instead of “Washington’s one-size-fits-all solutions” Texas is one of the 26 states involved in a multi-state lawsuit challenging the health law. Signed legislation in July 2011 to clear the path for Texas to join multi-state health care compacts. The compact would, if approved by Congress, enable the state to opt out of federal health care programs and receive federal funds to fulfill those responsibilities. “The federal government’s attempt to force every American to buy government-approved health insurance is an egregious violation of our Constitutional rights. The 10th Amendment and individual liberties must be protected, and I am committed to fighting the overreach of Obamacare and challenging these unconstitutional mandates, which have gone far beyond both the letter and spirit of the Constitution.” — Statement about district court ruling in Florida vs. HHS, Dec. 13, 2010 Medicaid Michele Bachmann (campaign suspended on Jan. 4) Strongly opposes the expansion of Medicaid and other low-income health programs such as CHIP; repeatedly has criticized the expansion of Medicaid under the health care law. Voted against the 2009 stimulus package, which included a temporary enhanced federal matching rate for the Medicaid program, as well as short-term COBRA continuation assistance. Voted against expanding CHIP in 2009 and 2007. Denounced last year’s decision by Minnesota Gov. Mark Dayton to expand Medicaid coverage to nearly 100,000 state residents. Came under scrutiny after media outlets reported that the Christian counseling business she and her husband own received federal and state government funding, including Medicaid payments. Herman Cain (campaign suspended on Dec. 3) Advocates turning Medicaid into a block grant program and allowing states greater flexibility to set their own rules. Suggests providing federally subsidized vouchers to help those with incomes up to three times the federal poverty level to buy coverage. Would use Medicaid for high risk insurance pools or other options to help individuals with pre-existing conditions or at high-risk for illness obtain coverage. Jon Huntsman (campaign suspended on Jan. 16) Supports reducing federal funding for Medicaid and turning the program into a block grant to the states. As governor, implemented a preferred drug list to steer doctors and patients toward lower-cost medications, curb rising costs of Medicaid. Restored “optional” dental and vision benefits by raising funds through private donations. Expanded coverage by instituting a year-round open enrollment period for the Children’s Health Insurance Program. “Let states determine what the percentage of poverty levels are, and let public officials rise or fall on how local citizens feel about those decisions. They’re in a much better position to understand their vulnerable populations than at the federal level.” — Wall Street Journal, June 25, 2011 Rick Perry (campaign suspended on Jan. 19) Wants states to have more flexibility in administering Medicaid. Joined with 32 other governors to oppose the health law’s maintenance-of-effort provisions, which prevent states from tightening Medicaid eligibility through 2014. Opposes the health law’s expansion of Medicaid, arguing it will cost Texas taxpayers more than $27 billion over 10 years starting in 2014. Supports turning Medicaid into a block-grant program, which he says would “improve health care delivery, with innovation, flexibility and local input.” Pushed a plan late in 2010 to opt out of Medicaid, a proposal that drew resistance from health care and nursing home advocates. The 2010-2011 state budget signed by Perry included $12 billion in federal stimulus funds. Outlined a Medicaid vision in 2007 to reduce the number of uninsured Texans by restructuring federal Medicaid funding; unsuccessfully sought a waiver from the HHS to pursue the changes. Facing budget pressures, the state during Perry’s tenure as governor has relied on cuts to provider payments and controls on pharmacy expenses to rein in the program’s costs. Texas has the largest percentage of any state’s population that is uninsured, ranks 49th in Medicaid coverage of low-income people and ranks 49th in per capita state spending on Medicaid.
–Compiled by Marilyn Werber Serafini, Stephanie Stapleton, Lexie Verdon, Shefali Kulkarni, Jessica Marcy, Juan Gastelum and Karl Eisenhower.